Fictional SOAP Case – Non-Medical Interpretation
Read the following fictional SOAP note written by the primary care physician and write a non-medical interpretation of what it says.
S: Pt states that she occasionally leaks urine when she sneezes. No dysuria. Feels she has problems with nocturia. Denies constipation. One sexual partner and uses condoms. Periods regular- last period 2 weeks ago.
O: No flank tenderness bilateral. No suprapubic tenderness. VS WNL. Urine sample obtained and no gross hematuria noted. DRE and pelvic exam normal. Neuro exam WNL
A: This 40 YO female presents with asymptomatic involuntary urination that she has been experiencing for about 6 months. She did not mention it during her last visit, as she was embarrassed to discuss it. She is afebrile, no general malaise, is well nourished and has no flank or abdominal tenderness. Findings suggest stress incontinence.
P: Urine to lab for urinalysis. Patient instructed to keep diary of leakage- note time and foods and liquids consumed. Instructed in Kegel’s exercises. Pt to return in 2 weeks . May discuss possible cystometry.
Instructions
Write a non-medical interpretation of what the above SOAP note says. What method(s) did you use to interpret the clinical information? What were some challenges in interpreting the information?
